is a broken arm an ALS or BLS call?

[Smash]

question: would the person with the " uncomplicated extremity fracture" who now has a prehospital IV and is medicated in the field have a higher or lower ESI number, and would he or she be treated in front of the 75% of other patients due to now being under the influence of analgesics and with the prehospital IV already started?

I can't speak for the triage category question, but I have seen a study in which patients with a NOF fracture were more likely to recieve timely and adequate pain relief in hospital if they presented having already had IV pain relief in the field. So lack of prehospital analgesia is not just a prehospital issue, it effects the entire course of care the patient receives.

Untreated acute pain leads to significant ongoing physical, psychological and emotional problems. Adequate pain relief for any and all patients is not just some warm, fuzzy, nice to do thing so long as we have a medic who feels like doing it, it is an absolutely vital part of the overal management of patients and one of the most important things we can do in prehospital medicine.

 

[Scott33]

question: would the person with the " uncomplicated extremity fracture" who now has a prehospital IV and is medicated in the field have a higher or lower ESI number, and would he or she be treated in front of the 75% of other patients due to now being under the influence of analgesics and with the prehospital IV already started?

Well, they certainly wouldn't jump to the front of the line.

However, depending on the facility, type and dose of prehospital analgesia given, and triage nurse - they may be given a higher or lower priority. Should be noted though, that not all prehospital analgesia is opiate / opioid in nature, or requiring of an IV.

Triage is tailored to the individual, more than just trying to slot the chief complain into an algorithm, and an isolated fracture on its own means very little. The patient who had received 60mg of Toradol IM, and is now completely pain free, will obviously be given a different priority than the patient who presents with diffuse urticaria, wheezing and angioedema after having received Morphine.

Those are the two extremes of course, but they do say, if in doubt about the severity of a patient's presentation, then up-triage. But it is also true that if the place is packed with ESI-2s and 3s, then it is often better to downgrade isolated injuries.

When you hear "take them to fast-track" or "out to the waiting room", it very often means that they will be evaluated and treated a lot sooner than if they were to be allocated a bed in the main ED.

 

[princessretard]

That is a problem, however even the two year EMS Degrees seem to have been watered down with a bunch of management or general education requirements which means you spend maybe half your time learning what is already an inadequate amount about the praxis of prehospital medicine.

In the countries that require Bachelors and Advanced Degrees for Paramedic or Intensive Care level we focus specifically on Paramedicine and specalise from semester one of year one with maybe one general education class required across the three years of the degree. Mind you this is a feature of all our degrees because we do thirteen years of high school at least in NZ and I believe in all Commonwealth countries.



In Australia where graduate medical education co-exists with the traditional six year courses they require a Bachelors Degree.



Oh please stop saying things.



Once again may I point out that the American notion of BLS vs ALS is utterly hillariously ridicoulous?

well, buddy, when you work in an area where als is hard to come by then you got no choice but to do the calls as bls. cant sit on scene waiting for the one als truck to show up to take the guy to the hospital. duh. the base i work out of has several bls trucks but only one als. so if the medics are busy and dispatch tells us als wont be able to intercept well then i guess thats that.

 

[LonghornMedic]

When you hear "take them to fast-track" or "out to the waiting room", it very often means that they will be evaluated and treated a lot sooner than if they were to be allocated a bed in the main ED.

I'm not sure how it works where you are, but if a patient is turfed to the waiting room, it's a safe bet they will be waiting for quite some time. We typically get bed assignments when we call in en route. But on rare days where a particular ER may be busy, patients in the waiting room will sit for over an hour.

 

[Flight-LP]

well, buddy, when you work in an area where als is hard to come by then you got no choice but to do the calls as bls. cant sit on scene waiting for the one als truck to show up to take the guy to the hospital. duh. the base i work out of has several bls trucks but only one als. so if the medics are busy and dispatch tells us als wont be able to intercept well then i guess thats that.

Actually you do have a choice. You can bring on a change that should have occured decades ago and promote the expansion of ALS services. Alternatively, you can continue to accept the mediocrity that currently exists and be content with offering minimal services to your community.

Your choice.

Either way, I'll add your area to my "don't get ill or injured" list.

 

[Sam Adams]

I'm not sure how it works where you are, but if a patient is turfed to the waiting room, it's a safe bet they will be waiting for quite some time. We typically get bed assignments when we call in en route. But on rare days where a particular ER may be busy, patients in the waiting room will sit for over an hour.

Now THAT is a pipe dream for us.... I can't even fathom getting room assignments over med control. The only time hospitals want us calling is if the pt needs the trauma/ resuscitation team. Also frequently the average waiting room time is well over 2, sometimes up into the 3 and 4 hour range. Not just for 1 of our hospitals, but many of them.

 

[boingo]

Well, we can argue for the "all ALS" system where everyone gets a paramedic v.s. the "tiered" system with a lot of BLS and fewer ALS vehicles reserved for high acuity patients.

One can claim that they always have ALS on every call, although I don't think there is any evidence suggesting that more ALS = better outcomes, although, at least in the setting of cardiac arrest, there is evidence that systems that operate in a "more BLS less ALS" configuration DO have better outcomes. Perhaps medics that see 8 high acuity patients a shift, do in excess of 20 intubations a year make more of a difference, (at least in cardiac arrest) than medics that see 7 low acuity patients, with maybe one in need of aggressive intervention a shift, and do less than 10 intubations a year.

If you saturate a system with paramedics you get paramedics who's learning curve is prolonged, be it EMT's and Paramedics in the U.S, Paremedics and Adavanced Care Paramedics in Canada, or any other configuration.

The folks in Australia and New Zealand are no different. They have fewer top end providers with more lesser (although certainly better educated than those in the U.S.) providers doing the majority of the work. Am I wrong?

As for pain management, I wish the BLS in the U.S. could administer pain meds, I don't think you need and ACP with RSI, thrombolytics and chest tubes to treat and transport a simple fx.

 

[MrBrown]

Last time I checked Intensive Care Paramedics made up around 10% of our workforce and I think it might have gone up a bit in recent years.

You do not need a configuration of all top-tier practitioners in order to be effective and infact many systems (particularly in AU and NZ, although to a degree in some Canadian provinces) are giving skills and knowledge that was once the domain of the advanced level officer to those below him.

In an "all ALS" model you have a large number of pracitioners competing for a limited number of opportunities to apply knowledge and skill which will not be met and people get atrophy and clinically stagnant. By giving the necessary skill and education options to first-tier crews you reduce the number of unnecessary requests for Intensive Care (for a bit of adrenaline or morphine etc) and increase thier avaliability for complex medical emergencies.

 

[clibb]

Lots of factors:
-CMS
-How long ago the fracture happened.
-What type of pain the pt is experiencing.

But this is usually a BLS call.

 

[Veneficus]

searching...

I am still hoping somebody will explain to me if a fx is a bls event that requires so little, why a physician needs to be involved?

 

[MrBrown]

I am still hoping somebody will explain to me if a fx is a bls event that requires so little, why a physician needs to be involved?

Legal reasons, why else is a Doctor involved in 99% of medicine in the US?

 

[EMS/LEO505]

Are you in Mike F or Mike V's class (I was in F's class)? And yea, SVFD does tend to use them a lot, but they've gotten some of CNMs last few medic classes, so hopefully that will start to go away. As for Tijeras... I don't know a lot about that area other than it's on the edge of BCFD and AAS response areas... and neither of those services carry PASG

Mike F, we still have to train in them because they are still in use in this state lol

 

[DrParasite]

I am still hoping somebody will explain to me if a fx is a bls event that requires so little, why a physician needs to be involved?

ummm, because definitive medical care is an MD?

It's BLS because "prehospitally" (you know, before you get to the hospital) it can be manged safely by BLS (unless you get a patient who refuses to move until you call for a paramedic, but I digress), packaged, and transported to a hospital (you know, with doctors) where X-rays can be taken, and permanent interventions can be applied, at least until their PMD can follow up with them.

Just like your medical director doesn't need to respond to the scene of a fx, and even if he does, he still wants you transported to the hospital so you can run all his fancy tests.

 

[johnrsemt]

depends if it is your arm that is broken or not:

I worked with medics that refused to give pain meds; and kept telling me that I was too liberal with them; but then would state that if they were ever hurt they wanted me to respond because they knew that I would treat their pain.

Had a supervisor/Medic call for an intercept one day, with a manager/patient with a head injury: the way it sounded on the radio, supervisor took run with narcotics. when I got there, supervisor had narcs, just wasn't comfortable giving them to patient, wanted me to give them, and then give patient care back to her.

 

[46Young]

I think that the reason some medics are hesitant to give narcotics is because they're either phobic of screwing up the administration, or more likely they're just lazy, and don't want to go through the process of documentation, restock, etc.

 

[rhan101277]

I think that the reason some medics are hesitant to give narcotics is because they're either phobic of screwing up the administration, or more likely they're just lazy, and don't want to go through the process of documentation, restock, etc.

I had an opportunity to give some yesterday for a broken arm that initially I couldn't see any deformity. But upon moving pt. to backboard it flopped around. The patient was in pain for sure. She had pulse,motor, sensory in the affecting extremity. But she was geriatric, was AAOx3, heart rate of 47, blood pressure was ok, but with all of the heart meds she was on, suspicious ST depression but I only had a 3 lead so its not diagnosable. I was hesitant. Concerned that a dramatic BP drop could occur for which her cardiovascular system may not be able to compensate for. Thinking back I could have called med control, but we were only 8 minutes out.

It bothered me to not administer it, since no contraindications existed. I think I made a good clinical decision though.

 

[46Young]

I had an opportunity to give some yesterday for a broken arm that initially I couldn't see any deformity. But upon moving pt. to backboard it flopped around. The patient was in pain for sure. She had pulse,motor, sensory in the affecting extremity. But she was geriatric, was AAOx3, heart rate of 47, blood pressure was ok, but with all of the heart meds she was on, suspicious ST depression but I only had a 3 lead so its not diagnosable. I was hesitant. Concerned that a dramatic BP drop could occur for which her cardiovascular system may not be able to compensate for. Thinking back I could have called med control, but we were only 8 minutes out.

It bothered me to not administer it, since no contraindications existed. I think I made a good clinical decision though.

If you were using a LP 12, you can change the monitor function from "monitor" to "diagnostic." This lets you view the leads as if it were an actual 12 lead. At the minimum, you could see II, III, and AVF and assess for any ischemic changes. The morphology differs somewhat from monitor and diagnostic mode. Try it on yourself when you go back to work.

You can bolus for the BP drop. Perhaps you could have called OLMC to be safe, maybe started a conservative plan with 1 mg of MS. I'd be suprised if a mg or two would bottom out the pt. I'm assuming that her HR is controlled medically and wouldn't be able to rise in response, but still. I'd be more worried about the effect of severe pain on the pt.

 

[Veneficus]

You can bolus for the BP drop. Perhaps you could have called OLMC to be safe, maybe started a conservative plan with 1 mg of MS. I'd be suprised if a mg or two would bottom out the pt. I'm assuming that her HR is controlled medically and wouldn't be able to rise in response, but still. I'd be more worried about the effect of severe pain on the pt.

OLMC is one of my best friends

Not to split hairs, but I don't see the purpose of extremely small doses of narcotic over time.

If you are using morphine, the recognized dose outside of easy to read EMS protocol numbers is 0.15mg/kg.

If this elderly person weighs 50 kg. that is 7.5 mg. let's cut it in 1/2 for potential increased potency from effects of aging, gets you 3.75 call it 4 because I don't know anyone who i going to portion out 0.75 mg of MS.

By those numbers if you gave 1mg every 2 minutes, it would take you 6 minutes to even get to the predicted level of effect. In an 8 minute ride that sort of bites.

If the BP starts to drop, since the vasculature is still a closed container, you can just add a little fluid. Probably won't even need 500ml.

BP controlled, pain hopefully controlled, if not, decide what to do at that point based on presentation.

Personally I would rather have a person a bit snowed and feeling no pain then take the time to do all the work and get nothing out of it.

Just the way I think.

 

[46Young]

OLMC is one of my best friends

Not to split hairs, but I don't see the purpose of extremely small doses of narcotic over time.

If you are using morphine, the recognized dose outside of easy to read EMS protocol numbers is 0.15mg/kg.

If this elderly person weighs 50 kg. that is 7.5 mg. let's cut it in 1/2 for potential increased potency from effects of aging, gets you 3.75 call it 4 because I don't know anyone who i going to portion out 0.75 mg of MS.

By those numbers if you gave 1mg every 2 minutes, it would take you 6 minutes to even get to the predicted level of effect. In an 8 minute ride that sort of bites.

If the BP starts to drop, since the vasculature is still a closed container, you can just add a little fluid. Probably won't even need 500ml.

BP controlled, pain hopefully controlled, if not, decide what to do at that point based on presentation.

Personally I would rather have a person a bit snowed and feeling no pain then take the time to do all the work and get nothing out of it.

Just the way I think.

Thanks, it makes sense when you put it that way.

 

[Aidey]

^^^ I actually prefer to give Fentanyl that way because of its shorter duration. I usually give a loading dose, and then 2-3 smaller doses after that (or more depending on transport time) so that there is a slight chance it won't wear off before the ER can give them anything.